Original Research published: 10 November 2015 doi: 10.3389/fmed.2015.00080
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Silvia Rollefstad1 , Eirik Ikdahl1 , Jonny Hisdal2 , Tore Kristian Kvien3 , Terje Rolf Pedersen4,5 and Anne Grete Semb1* Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway, Section of Vascular Investigations, Oslo University Hospital Aker, Oslo, Norway, 3 Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway, 4 Centre of Preventive Medicine, Oslo University Hospital, Oslo, Norway, 5 Faculty of Medicine, University of Oslo, Oslo, Norway 1 2
Edited by: Burkhard Franz Leeb, State Hospital Stockerau, Austria Reviewed by: George Bertsias, University of Crete, Greece Andreja Sinkovic, University Medical Centre Maribor, Slovenia *Correspondence: Anne Grete Semb
[email protected] Specialty section: This article was submitted to Rheumatology, a section of the journal Frontiers in Medicine Received: 11 July 2015 Accepted: 26 October 2015 Published: 10 November 2015 Citation: Rollefstad S, Ikdahl E, Hisdal J, Kvien TK, Pedersen TR and Semb AG (2015) Association of Chest Pain and Risk of Cardiovascular Disease with Coronary Atherosclerosis in Patients with Inflammatory Joint Diseases. Front. Med. 2:80. doi: 10.3389/fmed.2015.00080
Frontiers in Medicine | www.frontiersin.org
Objectives: The relation between chest pain and coronary atherosclerosis (CA) in patients with inflammatory joint diseases (IJD) has not been explored previously. Our aim was to evaluate the associations of the presence of chest pain and the predicted 10-year risk of cardiovascular disease (CVD) by use of several CVD risk algorithms, with CA verified by multidetector computed tomography (MDCT) coronary angiography. Methods: Detailed information concerning chest pain and CVD risk factors was obtained in 335 patients with rheumatoid arthritis and ankylosing spondylitis. In addition, 119 of these patients underwent MDCT coronary angiography. results: Thirty-one percent of the patients (104/335) reported chest pain. Only six patients (1.8%) had atypical angina pectoris (pricking pain at rest). In 69 patients without chest pain, two thirds had CA, while in those who reported chest pain (n = 50), CA was present in 48.0%. In a logistic regression analysis, chest pain was not associated with CA (dependent variable) (p = 0.43). About 30% (Nagelkerke R2) of CA was explained by any of the CVD risk calculators: Systematic Coronary Risk Evaluation, Framingham Risk Score, or Reynolds Risk Score. conclusion: The presence of chest pain was surprisingly infrequently reported in patients with IJD who were referred for a CVD risk evaluation. However, when present, chest pain was weakly associated with CA, in contrast to the predicted CVD risk by several risk calculators which was highly associated with the presence of CA. These findings suggest that clinicians treating patients with IJD should be alert of coronary atherosclerotic disease also in the absence of chest pain symptoms. Keywords: atherosclerosis, chest pain, cardiovascular diseases, inflammatory joint diseases, risk factors
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November 2015 | Volume 2 | Article 80
Rollefstad et al.
Atherosclerosis in Inflammatory Joint Diseases
INTRODUCTION
side(s) of thorax, radiating to throat/jaw or out in the arms/back and related to physical activity, as walking up hill/steps, walking indoors/flat, or while performing housework. In order to distinguish possible CA that would demand urgent invasive investigations, from stable coronary artery disease, patients were also asked questions to clarify the duration, frequency, persistence, and activity level needed to trigger the pain. Our cohort consisted of patients with low-intensity chest pain who were not in need of immediate assessment with selective coronary angiography. Patients with RA and AS at moderate to high risk of CVD and/or presence of chest pain were referred to MDCT coronary angiography. This is an observational report from a quality assurance register. Ethical approval and informed patient consent was therefore not required. The data collection/publication has been recommended and approved by the Oslo University Hospitals’ Office of Privacy and Data Protection (2011/7318).
Patients with inflammatory joint diseases (IJD) have an increased risk of cardiovascular disease (CVD) (1–3). Despite this wellestablished knowledge, implementation of CVD risk evaluation as a part of standard care in patients with IJD is deficient (4, 5). Chest pain is a vital symptom of coronary atherosclerotic disease, and its presence is addressed as a natural part of a CVD risk assessment. Chest pain in patients with IJD may be related to angina pectoris or to the rheumatic disease itself, and it can be clinically difficult to distinguish between the two for both the patient and the physician. The relation between chest pain and coronary disease in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) has not been explored previously. Angina pectoris is a symptom of myocardial ischemia caused by coronary atherosclerosis (CA) and may be diagnosed by several techniques. The selective coronary angiography procedure has become the gold standard for diagnosis of CA. This is an invasive, expensive, and resource-demanding procedure. Multidetector computed tomography (MDCT) coronary angiography is another imaging technique for identifying CA (6). Although both methods share the risks of radiation exposure and adverse reactions to contrast medium, MDCT coronary angiography has certain advantages over selective coronary angiography in that it is less costly, more time efficient, and entails a lower risk of CVD complications due to its non-invasiveness. The clinical utility of MDCT coronary angiography in predicting important CVD outcomes has been evaluated in several studies (7–9). The method is suitable for detection of CA in patients with moderate risk of CVD (10), and due to the high negative predictive value, it is particularly useful for excluding coronary stenosis (11). The aim of the present report was to characterize and compare the various types of chest pain in patients with RA and AS who were referred for a CVD risk evaluation. Furthermore, we sought to evaluate the associations of the presence of chest pain and the predicted 10-year risk of CVD by use of several CVD risk algorithms, with CA (verified by MDCT coronary angiography).
MDCT Coronary Angiography
The MDCT coronary angiography examination was performed at the Oslo University Hospital, Ullevaal. Two methods were used: first, spiral coronary artery MDCT, where 64 detectors were employed. This method is advantageous when performing reconstruction of the coronary arteries in several planes, including a three-dimensional plane. Furthermore, images of the coronary arteries may be reconstructed during all stages of the electrocardiogram (ECG) cycle. Second, the step and shoot technique was used. This is an ECG-gated MDCT coronary angiography method to reduce movement artifacts during the cardiac contraction cycle. To obtain optimal image quality with minimal movement artifacts, the heart rate should be
